Att1 CTO Mar06

Chronic Total Occlusion of the Chronic Total Occlusion of the Coronary ArteryCoronary Artery

Kirk Garratt, MDLenox Hill Hospital

What is a Chronic Total Occlusion?What is a Chronic Total Occlusion?

A complete blockage of a coronary A complete blockage of a coronary arteryartery Typically described as Typically described as >>99% 99% stenosedstenosed

Duration >3 monthsDuration >3 months Responsible for clinically significant Responsible for clinically significant

decrease in blood flow (TIMI 0decrease in blood flow (TIMI 0--1)1)

Chronic Total Occlusion

Hard Plaque Fibrocalcific >50% Collagen/Ca++

Soft Plaque >50% Cholesterol Macrophages Loose Fibrous Tissue

CTO vs. non-CTO

CTO lesion Non - CTO lesion

CTO ProcedureCTO Procedure

Prevalence of Chronic Total Occlusions in Patients with Coronary Artery

Disease

Pts withCTO30%

Pts without

CTO70%

Cardiac Data Sources, BLG Group

Treatment Options

9%

18%

73%

22%

31%

47%

Bypass AngioplastyMedical

Patients without CTOPatients with CTO

Delacretaz et al, 1997

Percutaneous CTO Treatment Reduces the Need For CABG 50% - 75%

PercutaneousPercutaneous Treatment of Treatment of CTOsCTOs

Success rates of recanalizing CTOs: 47%72% Requires greater skill, longer case time Technology development has not increased success

rates

Serious complication rates similar to non-CTO All complications rate: 6.8% to 20% More resource intensive (greater radiation and

fluoroscopy exposure, increased device utilization, increased cath lab time, etc.)

Bell MR, Et al: Circularion 1992: 85:1003-1011Plante S, Et. Al: Am Heart J 1991; 121:417Ruocco NA, Et al: Am J Cardiol 1992; 69:69-76Safian RD, Et al: Am J Cardiol 1988; 61:23G-28G

Chronic Total Occlusion

Most frequently identified yet least likely to be treated lesion subset in interventional cardiology today. 1

I have heard of hospitals that do not want cardiologists taking on CTOs because they tie up the cath lab. 2

1 Kandzari DE, Evidence-based rationale for CTO revascularization. TCT 2005, Washington DC2 Rutherford B. heartwire November 4, 2005, theheart.org

PCI Complexity Index by Multivariate Analysis

Variable ScoreNo of complex lesions 1.0Bifurcation stenting 1.5Ostial stenting 0.8CTO > 3 months 2.8Severe Tortuosity 4.9Complexity Index

Bernardi et al, CCI 2000, 51:1-9

CTO SummaryCTO Summary

Common disorder with inconsistent, non-uniform treatment patterns

Associated with high resource consumption Increased restenosis risk Failure to treat associated with worse early and

late patient outcomes

Tracking CTO TherapiesTracking CTO Therapies

Although documentation exists, limited ability to track CTO procedural volume means: Cannot accurately ascertain number of treated and untreated

CTOs Difficult to measure effect on CABG utilization rates Difficult to optimize management strategies in MVD Difficult to track outcomes across different treatment

modalities

Improved data capture can be used to track treatment outcomes and improve quality of care

How are CTOs documented?

Medical terminology: CTO common term used by Cardiologists

Physicians will specify the lesion as a chronic total occlusion of the coronary artery

Documentation of chronic total occlusionmay be found on:

Coronary angiography reports Interventional cardiology reports Operative reports History and physical and progress notes

The IntentThe Intent

More physicians will have data on the importance in More physicians will have data on the importance in treating treating CTOsCTOs

More understanding and data will exist on the clinical More understanding and data will exist on the clinical outcomes of various treatment optionsoutcomes of various treatment options

Improve treatment strategies to optimize quality of Improve treatment strategies to optimize quality of lifelife

Any Questions?

Chronic Total Occlusion of the Coronary ArteryWhat is a Chronic Total Occlusion?Chronic Total OcclusionCTO vs. non-CTOPrevalence of Chronic Total Occlusions in Patients with Coronary Artery DiseaseTreatment OptionsPercutaneous CTO Treatment Reduces the Need For CABG 50% - 75%Percutaneous Treatment of CTOsChronic Total OcclusionPCI Complexity Index by Multivariate AnalysisCTO SummaryTracking CTO TherapiesHow are CTOs documented?The IntentAny Questions?